Provider Demographics
NPI:1609862531
Name:LAVALLEY, MARY ELIZABETH (CPNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:LAVALLEY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5501 N 19TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2456
Mailing Address - Country:US
Mailing Address - Phone:602-249-9161
Mailing Address - Fax:602-246-2853
Practice Address - Street 1:5501 N 19TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2456
Practice Address - Country:US
Practice Address - Phone:602-249-9161
Practice Address - Fax:602-246-2853
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1091363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS66216Medicare UPIN